Promoting fusion in minimally invasive lumbar interbody stabilization with low-dose bone morphogenic protein-2--but what is the cost?

BACKGROUND

Using bone morphogenic protein (BMP) to augment fusion in spine surgery is widespread and lends itself in particular to minimally invasive lumbar fusion, where the surface area for fusion is significantly less than the equivalent open procedure.

PURPOSE: Here we described the use of very low-dose BMP in promoting fusion in minimally invasive lumbar interbody fixation but also highlight some of the potential complications of BMP-2 use and techniques available to reduce or avoid them.

STUDY

DESIGN

Prospective observational study of consecutive patients undergoing minimally invasive lumbar interbody fusion with percutaneous pedicle screws.

PATIENT SAMPLE: Thirty patients aged between 22 and 78 years (mean 53 years).

OUTCOME MEASURES: Thin-slice lumbar computed tomography scanning with multiplanar reconstruction at 6 and 12 months postoperative.

METHODS

Thirty-six spinal levels were instrumented in total, of which four underwent posterior lumbar interbody fusion and 32 underwent transforaminal lumbar interbody fusion. Bone graft harvested locally was placed in the disc space with low-dose BMP-2 (1.4 mg per level).

RESULTS

Thirty-three of 36 spinal levels showed complete fusion at a mean postoperative scan time of 7.1 months. Two levels demonstrated partial fusion at 6 months, which was complete at 12 months. There was one case of nonunion at 12 months, which also demonstrated vertebral body osteolysis. Despite very low-dose BMP-2, two cases of asymptomatic heterotopic ossification were observed, and there were two cases of perineural cyst formation, one of whom required revision of the interbody cage.

CONCLUSIONS

The use of BMP with autograft in the disc space during minimally invasive lumbar interbody fusion is associated with a high rate of early fusion. Even with very low-dose BMP used in this study, complications related to BMP usage were not avoided completely.